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HHS Public Access
Author manuscript
J Correct Health Care. Author manuscript; available in PMC 2021 July 31.
Author Manuscript
Published in final edited form as:
J Correct Health Care. 2020 July ; 26(3): 279–291. doi:10.1177/1078345820939512.
Suicides Among Incarcerated Persons in 18 U.S. States:
Findings From the National Violent Death Reporting System,
2003–2014
Kristiana J. Dixon, PhD1, Allison M. Ertl, PhD1, Rachel A. Leavitt, MPH1, Kameron J.
Sheats, PhD1, Katherine A. Fowler, PhD1, Shane P. D. Jack, PhD1
1Division
of Violence Prevention, National Center for Injury Prevention and Control, Centers for
Author Manuscript
Disease Control and Prevention, Atlanta, GA, USA
Abstract
Using data from the National Violent Death Reporting System (2003–2014), this study examined
the characteristics and contributing circumstances of suicides in correctional facilities. χ2 and
logistic regression analyses revealed that, compared to nonincarcerated suicide decedents,
incarcerated suicide decedents had significantly lower odds of positive toxicology for substances
but significantly higher odds of substance abuse problems. Descriptive subanalyses indicated that
incarcerated suicide decedents often were incarcerated for personal crimes. They often died ≤ 1
week of incarceration, in a cell (frequently single-person or segregation), by hanging, using
bedding material. Positive toxicology was more common for incarcerated decedents who died
shortly after versus later in their incarceration. Findings highlight the need for enhanced detection
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and treatment of suicidal behavior, especially during early and vulnerable periods of incarceration.
Keywords
suicide; incarceration; inmate; jail; prison
Suicide rates are higher among incarcerated than nonincarcerated persons (Konrad et al.,
2007; Snow et al., 2002). In 2014, the suicide rate was 50 per 100,000 jail inmates (Noonan,
2016a), 20 per 100,000 state prisoners, and 14 per 100,000 federal prisoners (Noonan,
2016b), while the age-adjusted suicide rate for the entire U.S. population was 12.9 per
100,000 (Centers for Disease Control and Prevention [CDC], 2017).
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Several factors may contribute to increased rates of suicide for incarcerated individuals,
including personal and life circumstances, the incarceration process, and the correctional
environment (World Health Organization [WHO], 2007). Many incarcerated individuals are
more vulnerable to suicide even prior entering the correctional system due to previous
suicidal thoughts and behavior, mental illness, substance use problems, and/or economic and
Corresponding Author: Allison Ertl, PhD, Division of Violence Prevention, Centers for Disease Control and Prevention, 4770 Buford
Hwy, MS F-63, Atlanta, GA 30341, USA., moq4@cdc.gov.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.Dixon et al. Page 2
social disenfranchisement (Blaauw et al., 2005; WHO, 2007). Other individual-level factors
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that have been associated with suicides among incarcerated persons include first
incarceration, being male, being White, and young age (Cramer et al., 2017).
However, the incarceration process also may elevate the likelihood of suicidal behavior due
to accompanying stressors such as loss of autonomy and freedom, reduced social (family
and friends) and financial support, substance withdrawal, and feelings of hopelessness,
shame, and embarrassment (Cramer et al., 2017; WHO, 2007). Stress associated with legal
aspects of incarceration (e.g., sentence length) and facing the reality of incarceration also
may increase inmates’ vulnerability for suicide (Cramer et al., 2017), as research suggests
that suicides are more likely to occur during the first few months of incarceration, in close
proximity to court hearings, and among those with long sentence lengths (Cramer et al.,
2017; Hayes, 2010).
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Features of the correctional environment also may affect suicidal behavior, including over-
crowded facilities, a combative culture with regular use of force by other inmates and
correctional officers, and overworked and undertrained facility staff (Cramer et al., 2017;
WHO, 2007). Segregated and single-cell housing can restrict movement and create social
isolation that can contribute to psychological deterioration and increased risk of suicide. In
addition, individuals in isolated housing often experience other risk factors for suicide, such
as new disciplinary charges, reduced privileges, psychological distress, and medical and
psychiatric conditions (Reeves & Tamburello, 2014). Inadequate or limited access to health
and mental health services and a shortage of sufficiently trained mental health practitioners
also may contribute to increased vulnerability for suicide among inmates due to reduced
availability of mental health treatment and suicide prevention services (Cramer et al., 2017).
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This study aimed to identify circumstances and characteristics of suicides among
incarcerated persons and compare them with suicides of nonincarcerated persons to identify
factors unique to this population, all of which can guide suicide prevention efforts in
correctional settings.
Method
Data Source
Data came from CDC’s National Violent Death Reporting System (NVDRS), a state-based,
active surveillance system that collects detailed information on all violent deaths (including
suicides) occurring in participating states. NVDRS collates data from death certificates, law
enforcement reports, and coroner/medical examiner records. Trained data abstractors extract
information on the characteristics and circumstances of these deaths using standardized
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CDC protocols and write narratives that provide a descriptive summary of events preceding
the death (Blair et al., 2016).
Case Selection and Narrative Coding
Cases included all suicide decedents from the 18 states that participated in NVDRS during
2003–20141 where the decedent was ≥ 10 years of age. Incarcerated suicide decedents
included all individuals detained at a law enforcement or correctional facility when fatally
J Correct Health Care. Author manuscript; available in PMC 2021 July 31.Dixon et al. Page 3
injured. Suicide decedents were not considered incarcerated if under arrest but not detained,
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on community supervision, residing at a halfway house or detoxification facility, or off-site
on work release when fatally injured.
For all incarcerated suicide cases, the authors coded case narratives for additional variables,
including (a) special housing assignment (e.g., segregation, medical or mental health unit),
(b) single-person cell (no cellmates; yes/no), (c) facility location where fatally injured (e.g.,
cell, bathroom), (d) ligature mechanism (when applicable; e.g., bedding, clothing), (e)
anchoring location or device (when applicable; e.g., bed, door), (f) criminal charge(s) or
offense(s) (e.g., personal, property), (g) length of time incarcerated for current offense(s)
when fatally injured (e.g., ≤1 day, 2 to 7 days, 8 days to 1 month), and (h) upcoming release2
(yes/no). The authors coded 200 initial case narratives to assess pairwise inter-rater
reliability, ranging from κ = 0.66 (single-person cell) to κ = 1.00 (upcoming release).
Coding discrepancies were resolved by group discussion. The remaining cases were divided
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among the authors and coded independently. When unsure about coding decisions, final
determinations were made by the first author or through coauthor group discussion.
Statistical Analysis
Demographics, incident characteristics, and precipitating circumstances were examined by
incarceration status (incarcerated vs. nonincarcerated) using χ2 tests. Significant results
were examined further using logistic regression, controlling for age, sex, and race/ethnicity.
A descriptive subanalysis of incarcerated suicides was conducted with the additional
variables coded from case narratives.
Results
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Incarcerated Versus Nonincarcerated Suicide Decedents
There were 1,896 incarcerated suicide decedents and 121,512 nonincarcerated suicide
decedents (Table 1). Incarcerated decedents were significantly younger than nonincarcerated
decedents at the time of death; the largest proportion (44.4%) of incarcerated decedents was
aged 25 to 39 years, whereas the largest proportion (41.2%) of nonincarcerated decedents
was aged 40 to 59 years. Although the majority of both incarcerated and nonincarcerated
decedents was male (91.2% and 77.9%, respectively), a significantly higher proportion of
incarcerated decedents was male. Incarcerated decedents were significantly more likely to be
racial/ethnic minorities; 33.8% of incarcerated decedents were racial/ethnic minorities (non-
Hispanic, Black = 17.6%; Hispanic = 10.1%; non-Hispanic, other = 6.1%) versus 15.3% of
nonincarcerated decedents (non-Hispanic, Black = 6.3%; Hispanic = 4.5%; non-Hispanic,
other = 4.5%). Incarcerated decedents had half the odds of being married or in a civil union
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as compared with nonincarcerated decedents (p < .05, adjusted odds ratio [aOR] = 0.52; CI
1.In 2003, NVDRS began data collection with six states (Maryland, Massachusetts, New Jersey, Oregon, South Carolina, and
Virginia); seven additional states (Alaska, Colorado, Georgia, North Carolina, Oklahoma, Rhode Island, and Wisconsin) joined in
2004, three (Kentucky, New Mexico, and Utah) in 2005, and two (Ohio and Michigan) in 2010. Ohio collected statewide data starting
in 2011 and Michigan starting in 2014.
2.Upcoming release was coded anytime the narratives mentioned the decedent being released or a release date (regardless of time),
including that the decedent was scheduled or going to be released in the near future (e.g., “the decedent was going to be released soon”
or “the decedent’s release date was coming up”).
J Correct Health Care. Author manuscript; available in PMC 2021 July 31.Dixon et al. Page 4
[0.46, 0.59]). The mechanism of fatal injury for the majority (52.5%) of nonincarcerated
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decedents was a firearm, whereas 92.2% of incarcerated decedents died by asphyxiation,
with over 33 times the odds of dying by this mechanism (p < .05, aOR = 33.02; CI [27.85,
39.14]).
Circumstance information was known for 90.0% of incarcerated and 89.3% of
nonincarcerated suicides. Intimate partner problems had significantly lower odds of being
noted for incarcerated than nonincarcerated suicide decedents (aOR = 0.25; CI [0.22, 0.29]).
Incarcerated decedents had significantly higher odds of having perpetrated violence in the
past month (aOR = 1.29; CI [1.07, 1.54]) and to have contributing criminal legal problems
(aOR = 14.63; CI [13.19, 16.24]) compared with nonincarcerated decedents. Suicides of
incarcerated persons had significantly higher odds of being related to a serious crime (e.g.,
robbery; aOR = 2.13; CI [1.72, 2.65]), which may or may not have been the crime for which
they were incarcerated.
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Current diagnosed mental health problems overall (aOR = 0.74; CI [0.67, 0.82]), a diagnosis
of depression (aOR = 0.53; CI [0.47, 0.60]), current depressed mood (aOR = 0.36; CI [0.32,
0.41]), and alcohol problems (aOR = 0.49; CI [0.42, 0.57]) were significantly less likely to
be reported among incarcerated decedents. However, incarcerated decedents were
significantly more likely to have a known diagnosis of schizophrenia (aOR = 1.20; CI [0.93,
1.57]), unspecified mental health diagnosis (aOR = 1.69; CI [1.40, 2.05]), or a reported
substance abuse problem other than alcohol (aOR = 1.18; CI [1.05, 1.33]). Incarcerated
decedents had lower odds of currently (aOR = 0.83; CI [0.74, 0.93]) or ever (aOR = 0.82; CI
[0.74, 0.91]) having received mental health or substance abuse treatment, having a history of
suicidal thoughts (aOR = 0.62; CI [0.48, 0.79]), leaving a suicide note (aOR = 0.70; CI
[0.63, 0.79]), or disclosing suicidal intent (aOR = 0.50; CI [0.44, 0.57]). Among incarcerated
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decedents who disclosed suicidal intent, 45.2% disclosed to someone in the correctional
system, such as a cellmate, another inmate, a correctional officer, or other/unspecified
correctional staff,3 and 27.4% disclosed to a family member other than an intimate partner.
Incarcerated decedents had significantly lower odds of testing positive for substances at the
time of death; 7.1% tested positive for alcohol, 8.8% for marijuana, 4.0% for cocaine, and
8.2% for opiates.
Subanalysis of Incarcerated Suicide Decedents
The vast majority (92.8%) of incarcerated suicide decedents were in a cell when fatally
injured (Table 2). Among incarcerated decedents, 16.6% were reportedly housed without a
cellmate (8.2% were in segregation).4 Additionally, 4.4% of incarcerated decedents were
housed in holding or booking cells, 2.3% in a medical unit, and 1.8% in a mental health unit.
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When the length of incarceration was known, 24.1% were incarcerated for ≤ 24 hours and
55.5% were incarcerated for ≤ 1 week. The largest proportion of fatal injuries occurred
between noon and 6 p.m. (31.7%). When criminal offense(s) that led to incarceration were
3.For incarcerated decedents who disclosed suicidal intent to “other,” the first author reviewed and coded the accompanying text using
the following categories: cellmate, other inmate, correctional officer, other or unspecified correctional staff (e.g., health care
professional), police, and decedent’s attorney.
4.In this article, the terms segregation and isolated confinement are used synonymously.
J Correct Health Care. Author manuscript; available in PMC 2021 July 31.Dixon et al. Page 5
known, 46.1% were incarcerated for a personal crime5 and 23.4% for a substance-related
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crime. Among those incarcerated for a personal crime, 32.1% were held for assault/battery
and 27.6% for homicide.
The overwhelming majority (92.2%) of incarcerated decedents died by asphyxiation (Table
1), mostly by hanging (97.5%) (Table 3). When the ligature mechanism was known for
asphyxia deaths, most (71.8%) involved bedding. Of hanging deaths where the anchoring
point was known, over one third (35.7%) attached the ligature to a bed, 82.2% of which were
noted to be bunk beds.
Decedents who died within a week of incarceration tested positive for substances more often
than those who died more than a week after incarceration (Table 4). Of decedents known to
have died within 24 hours of incarceration who had available toxicology test results, 34.6%
tested positive for alcohol, 23.5% for marijuana, 11.6% for cocaine, and 7.3% for opiates.
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Discussion
Suicide is a concern for incarcerated persons, correctional institutions and staff, and inmates’
loved ones. Those with legal responsibility for correctional populations also have a vested
interest in ensuring inmates’ health and safety, including protection from self-harm, as a
failure to do so can expose correctional systems to liability (Konrad et al., 2007; WHO,
2007). The purpose of this analysis was to use a large multistate sample to examine suicides
among incarcerated populations to identify characteristics and circumstances that point to
opportunities for suicide prevention. The comparison of incarcerated and nonincarcerated
suicides provided a point of reference when describing the circumstances surrounding
incarcerated suicides.
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Incarcerated Versus Nonincarcerated Suicide Decedents
Incarcerated suicide decedents in this analysis were more likely than nonincarcerated suicide
decedents to be young, male, racial/ethnic minorities, and never married. This mirrors the
overall prison population in the United States (Carson & Sabol, 2016), perhaps suggesting
that inmate suicides are unrelated to these characteristics. Persons of color are incarcerated
disproportionately, possibly due to inequitable arrest and sentencing rates, especially among
young, Black males (Mauer & King, 2007; Spohn, 2013). Incarcerated decedents largely
were young and never married, which may be explained by the “aging out” of criminal
behavior (Loeber & Stallings, 2011; Sampson & Laub, 2003). Finally, incarcerated
decedents had higher odds of dying by hanging, whereas nonincarcerated decedents had
higher odds of dying by firearm, which points to decedents’ access to different lethal means.
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Incarcerated decedents were less likely to have a known diagnosed mental health condition
than nonincarcerated decedents. This was unexpected given the overall association of mental
health conditions with suicide and elevated rates of mental health conditions in incarcerated
populations (Al-Rousan et al., 2017; Bronson & Berzofsky, 2017; James & Glaze, 2006). A
5.Consistent with the Bureau of Justice Statistics violent crime category, personal crimes were defined as any violent crime perpetrated
against another person, including but not limited to domestic violence, homicide, assault, kidnapping, robbery, carjacking, false
imprisonment, and violation of a protective/restraining order. Sexual crimes (e.g., rape, sexual assault) were coded separately.
J Correct Health Care. Author manuscript; available in PMC 2021 July 31.Dixon et al. Page 6
previous study reported that approximately half of the most common mental health
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conditions (e.g., depression, anxiety) were recognized in the first month of incarceration (Al-
Rousan et al., 2017). The majority of suicides in our analysis occurred within a month of
incarceration, so some decedents’ mental health conditions may not have been recognized
yet. The resources for mental health evaluations may be limited in correctional facilities, and
problems with acquisition and completeness of inmates’ prior medical records also may
contribute to loss of mental health information, particularly given frequent interfacility
transfers (Al-Rousan et al., 2017). Others have emphasized the need for improved suicide
risk assessment at intake and other periods of high vulnerability (e.g., around court hearings
and facility transfers; Hayes, 2013) and continuity and tracking of care via electronic health
records (National Commission on Correctional Health Care, 2017).
Similar issues with substance abuse assessment and access to inmates’ previous records,
especially for those who died shortly after incarceration, may have resulted in
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underestimates of substance abuse problems. A 2004 Bureau of Justice Statistics (BJS)
survey found that over 50% of inmates met the Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition, criteria for drug dependence or abuse (Mumola & Karberg,
2006), and rates of arrest and incarceration for drug offenses have increased over time
(Federal Bureau of Investigation, 1996–2006). Although prior substance abuse problems
were present more often for incarcerated decedents in this analysis, the percentage (20.5%)
was lower than BJS estimates. Of note, incarcerated decedents had significantly lower odds
of testing positive for substances; however, this may be due to inmates’ restricted access to
substances rather than an indication of substance abuse. Altogether, this suggests the
importance of early identification of substance use disorders and appropriate treatment
(Konrad et al., 2007; WHO, 2007).
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Common Circumstances of Incarcerated Decedents
The current analysis highlights the impact of criminal legal factors on inmate suicide.
Hanging was the most common method of suicide for incarcerated decedents, consistent
with other findings (Hayes, 2012). Most suicides occurred in a cell, with ligatures made of
bedding, attached to beds (mostly bunk beds). Likely, suicides often occur in cells because
of the relative privacy and subsequent reduced likelihood of intervention. Although “suicide
proof” cells are impossible to create, others have recommended minimizing the use of bunk
beds; keeping beds low to the ground; using fully enclosed, solid bed slabs; and minimizing
or eliminating potential hanging points in cells (Blaauw et al., 2005; Hayes, 2011; Stone et
al., 2017).
Among incarcerated decedents in this analysis, 16.6% were housed in single-person cells
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(8.2% were in segregation). Comparatively, approximately 4.4% of prisoners and 2.7% of
jail inmates are housed in segregation or solitary confinement on an average day (Beck,
2015). Therefore, suicides appear to occur disproportionately among inmates housed in
single-person or segregation cells. Isolated housing has an established association with
suicide as often it is accompanied by further loss of privileges and uncertainty about the
future (e.g., additional disciplinary charges and increased sentence length; Reeves &
Tamburello, 2014). Additionally, those already at increased suicide risk may be more likely
J Correct Health Care. Author manuscript; available in PMC 2021 July 31.Dixon et al. Page 7
to be placed in segregated or single-cell housing; a report published by BJS (Beck, 2015)
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found that the use of restrictive housing was linked to inmate mental health conditions.
Moreover, single-person cells limit the opportunity for other inmates to intervene during a
suicide attempt (Reeves & Tamburello, 2014). Previous housing recommendations include
using the least restrictive housing necessary to ensure everyone’s safety and generally
avoiding restrictive housing for those with serious mental illness (U.S. Department of
Justice, 2016).
Incarcerated decedents often disclosed suicidal intent to family, other inmates, and
correctional staff. Educating family, inmates, and staff on the process of reporting suicidal
disclosures and developing mechanisms to ensure notifications are relayed to appropriate
facility personnel may reduce inmate suicide (Hayes, 2013). Additionally, some correctional
facilities have implemented inmate peer-to-peer programming to enhance social support and
prevent inmate suicide (Bagnall et al., 2015).
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Incarcerated decedents who died shortly after incarceration were more likely to have
substances in their system than those incarcerated longer. Although this finding likely is a
result of decreased access to substances while in custody, it also means that some inmates
are intoxicated and/or experiencing symptoms of withdrawal during early periods of
incarceration. Substance abuse is associated positively with suicide risk (Harford et al.,
2018) over and above mental health conditions like depression (Hawton et al., 2013);
substance withdrawal can heighten feelings of depression and anxiety, and intoxication can
lower behavioral inhibitions, both of which may exacerbate suicide risk (National Institute
on Drug Abuse, 2018; Trevisan et al., 1998). Therefore, withdrawal symptoms may amplify
the stress of recent incarceration and increase suicide vulnerability for some inmates (Fagan
et al., 2010). Altogether, this suggests the importance of screening and closely monitoring
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incoming inmates, especially those intoxicated or with known substance abuse problems
(Konrad et al., 2007; WHO, 2007), medically appropriate care during withdrawal, and
access to substance abuse treatment during incarceration (Fagan et al., 2010; Fiscella et al.,
2004).
Study Limitations
This analysis had several limitations. First, we did not have access to comparison data for
the general incarcerated population in the United States. Therefore, we were unable to
identify factors that increase suicide risk among all incarcerated persons; instead, we
compared incarcerated decedents with suicide decedents in the general population to identify
factors unique to this population. Second, we did not have access to data on institutional
factors such as facility type (jails, state prisons, federal prisons), security level, public versus
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private institutions, availability of resources, and policies, all of which may impact inmate
suicide and suicide prevention strategies. Third, data for this analysis came from the 18
states participating in NVDRS during the study period; therefore, the data are not nationally
representative. Moreover, the number of states included varied over time.1 Fourth, NVDRS
data are limited to information within source documents. Those investigating inmate deaths
may not have access to outside systems or persons with detailed information about
decedents, and inside informants’ knowledge may be limited due to the nature and length of
J Correct Health Care. Author manuscript; available in PMC 2021 July 31.Dixon et al. Page 8
relationships in correctional settings. Additionally, toxicology data are not collected in a
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consistent manner across all states, and toxicology testing is not conducted for all decedents.
Finally, several variables examined are not standard NVDRS data elements; therefore, their
availability within source documents and whether abstractors chose to include them in the
narrative determined whether they were captured. Consequently, the frequencies of these
particular characteristics likely are underestimates.
Implications
CDC’s suicide prevention technical package (Stone et al., 2017) describes several prevention
strategies based on the best available evidence and relevant to inmate suicides, including
strengthening access to and delivery of suicide care, creating protective environments, and
identifying and supporting vulnerable individuals. This resource points to detention facilities
as one setting where changing organizational culture to encourage help-seeking and placing
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more value on mental health could prevent suicide. Based on the current findings, efforts to
ensure that inmates with mental health or substance use disorders are identified and receive
appropriate services, especially during early and other high stress periods of incarceration,
may decrease inmate suicide. Organizational policies that engineer correctional
environments to minimize access to common means of suicide also may be effective in
reducing these deaths. Suicide prevention training could equip correctional administrators
and staff with the skills and resources to create a supportive culture and climate, recognize
and respond to signs of suicide, and employ effective suicide prevention measures.
Acknowledgments
This project was supported in part by an appointment to the Research Participation Program at the Centers for
Disease Control and Prevention administered by the Oak Ridge Institute for Science and Education through an
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interagency agreement between the U.S. Department of Energy and the Centers for Disease Control and Prevention.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
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Table 1.
Characteristics of Incarcerated Versus Nonincarcerated Suicide Decedents.
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Incarcerated Nonincarcerated
n = 1,896 n = 121,512
Characteristic or Circumstance n (%) n (%) χ2 aOR (95% CI)
Age group (years) a a
1,895 121,354
10 to 17 21 (1.1) 3,627 (3.0) 23.0*
18 to 24 324 (17.1) 12,406 (10.2) 95.2*
25 to 39 842 (44.4) 28,903 (23.8) 433.1*
40 to 59 660 (34.8) 49,948 (41.2) 30.9*
60+ 48 (2.5) 26,470 (21.8) 410.7*
Sex a a 195.5*
1,896 121,455
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Male 1,730 (91.2) 94,553 (77.9)
Female 166 (8.8) 26,902 (22.1)
Race/ethnicity a a
1,895 121,273
Non-Hispanic, White 1,256 (66.3) 102,730 (84.7) 482.0*
Non-Hispanic, Black 333 (17.6) 7,615 (6.3) 394.2*
Hispanic 191 (10.1) 5,442 (4.5) 133.7*
Non-Hispanic, other 115 (6.1) 5,486 (4.5) 10.3*
b a a 225.2* 0.52 (0.46, 0.59)
Marital status 1,836 119,825
Married/civil union 355 (19.3) 43,467 (36.3)
Not married 1,481 (80.7) 76,358 (63.7)
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Never married 972 (52.9) 38,537 (32.2)
Widowed 52 (2.8) 7,429 (6.2)
Divorced 400 (21.8) 26,665 (22.3)
Other 57 (3.1) 3,727 (3.1)
Mechanism a a
1,892 120,527
c 1 (0.1) 63,324 (52.5) 2,055.1*
Firearm
Asphyxiation 1,745 (92.2) 28,342 (23.5) 4,744.9* 33.02 (27.85, 39.14)
Sharp instrument 51 (2.7) 2,229 (1.9) 7.3* 1.57 (1.18, 2.07)
Poisoning 52 (2.8) 20,787 (17.3) 277.2* 0.18 (0.13, 0.24)
Fall 34 (1.8) 2,171 (1.8) 0.0
c 9 (0.5) 3,674 (3.1) 42.2*
Other
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Cases with known circumstances 1,706 (90.0) 108,521 (89.3)
Interpersonal relationships
Intimate partner problem 242 (14.2) 33,299 (30.7) 216.0* 0.25 (0.22, 0.29)
Perpetrator of violence in the past month 133 (7.8) 4,296 (4.0) 64.1* 1.29 (1.07, 1.54)
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Incarcerated Nonincarcerated
n = 1,896 n = 121,512
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Characteristic or Circumstance n (%) n (%) χ2 aOR (95% CI)
Life circumstances
Criminal legal problem 1,115 (65.4) 9,613 (8.9) 6,102.8* 14.63 (13.19, 16.24)
Precipitated by a serious crime 95 (5.6) 1,914 (1.8) 135.9* 2.13 (1.72, 2.65)
Behavioral health
Current diagnosed MH condition 577 (33.8) 48,809 (45.0) 84.5* 0.74 (0.67, 0.82)
Depression/dysthymia 311 (18.2) 36,946 (34.1) 187.8* 0.53 (0.47, 0.60)
Bipolar disorder 111 (6.5) 7,110 (6.6) 0.01
Schizophrenia 60 (3.5) 2,383 (2.2) 13.5* 1.20 (0.93, 1.57)
Anxiety 62 (3.6) 5,543 (5.1) 7.6* 0.90 (0.70, 1.16)
Other 91 (5.3) 4,950 (4.6) 2.3
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Not specified 117 (6.9) 4,542 (4.2) 29.6* 1.69 (1.40, 2.05)
Current depressed mood 324 (19.0) 44,719 (41.2) 343.0* 0.36 (0.32, 0.41)
Alcohol problem 179 (10.5) 19,430 (17.9) 63.1* 0.49 (0.42, 0.57)
Other substance problem 350 (20.5) 16,286 (15.0) 39.8* 1.18 (1.05, 1.33)
Current MH/SA treatment 422 (24.7) 35,448 (32.7) 48.1* 0.83 (0.74, 0.93)
Ever treated for MH/SA 517 (30.3) 41,869 (38.6) 48.6* 0.82 (0.74, 0.91)
d 83 (22.2) 7,901 (32.1) 16.7* 0.62 (0.48, 0.79)
Hx of suicidal thoughts
Hx of suicide attempts 340 (19.9) 21,638 (19.9) 0.0
Suicide note 397 (23.3) 36,680 (33.8) 83.4* 0.70 (0.63, 0.79)
Disclosed suicidal intent 285 (16.7) 30,563 (28.2) 109.4* 0.50 (0.44, 0.57)
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d
Disclosed to whom
Previous/current partner 8 (11.0) 3,368 (41.3)
Other family member 20 (27.4) 2,662 (32.6)
Health care worker 2 (2.7) 306 (3.8)
Friend/colleague 10 (13.7) 1,071 (13.1)
e 33 (45.2) 751 (9.2)
Other
f
Toxicology
Alcohol 101 (7.1) 27,898 (35.8) 500.7* 0.11 (0.09, 0.14)
Marijuana 74 (8.8) 4,689 (11.5) 6.1* 0.51 (0.40, 0.66)
Cocaine 48 (4.0) 3,715 (6.9) 15.8* 0.37 (0.28, 0.50)
Opiates 98 (8.2) 12,196 (22.5) 139.7* 0.41 (0.33, 0.50)
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Source: NVDRS, 18 U.S. States, 2003–2014.
Note. The aORs for the logistic regression analyses controlled for age group, sex, and race/ethnicity. Percentages may not add to 100% due to
rounding. NVDRS = National Violent Death Reporting System; aOR = adjusted odds ratio; CI = confidence interval; Hx = history; MH = mental
health; SA = substance abuse.
J Correct Health Care. Author manuscript; available in PMC 2021 July 31.Dixon et al. Page 13
a
Number of cases where this information was known.
b
Test is between married/civil union and not married.
c
Fisher’s exact test was conducted. Statistical reliability criteria for logistic regression were not met because cell frequencies were less than the
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minimum required.
d
Variable was added to NVDRS in 2013.
e
For incarcerated decedents, “other” included cellmates, other inmates, correctional officers, facility mental health professionals, other/unspecified
correctional staff, police, and the decedent’s attorney. For nonincarcerated decedents, “other” included neighbor, health care worker and intimate
partner, health care worker and other, and other (unspecified).
f
Of decedents who had a known test result, the total number and percentage of suicide decedents that tested positive for each substance.
Denominators for each are as follows: 1,417 incarcerated and 77,951 nonincarcerated suicide decedents had a known test result for alcohol; 846
incarcerated and 40,899 nonincarcerated suicide decedents had a known test result for marijuana; 1,198 incarcerated and 53,515 nonincarcerated
suicide decedents had a known test result for cocaine; 1,201 incarcerated and 54,239 nonincarcerated suicide decedents had a known test result for
opiates.
*
p < .05 for χ2 tests.
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Table 2.
Personal and Environmental Characteristics of Incarcerated Suicide Decedents.
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Incarcerated Suicide Decedents
n = 1,896
Characteristic n (%)
Facility location a
1,553
Cell 1,441 (92.8)
Bathroom/shower 64 (4.1)
Common area 29 (1.9)
Off-grounds 5 (0.3)
Other, on-grounds 14 (0.9)
b a
Special housing 476
Single-person cell (including segregation) 314 (16.6)
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Holding/booking 84 (4.4)
Medical unit 44 (2.3)
Mental health unit 34 (1.8)
Time incarcerated a
669
c 590 (88.2)
Recently incarcerated
1 day or less 161 (24.1)
2 to 7 days 210 (31.4)
8 days to 1 month 84 (12.6)
31 days to 6 months 81 (12.1)
Unspecified 54 (8.1)
181 days to 1 year 24 (3.6)
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366 days to 5 years 27 (4.0)
More than 5 years 28 (4.2)
Time of injury a
1,066
Morning (6:00 a.m. to 11:59 a.m.) 221 (20.7)
Afternoon (12:00 p.m. to 5:59 p.m.) 338 (31.7)
Evening (6:00 p.m. to 11:59 p.m.) 287 (26.9)
Overnight (12:00 a.m. to 5:59 a.m.) 220 (20.6)
Offense type a
959
Personal 442 (46.1)
Homicide 122 (27.6)
Robbery 75 (17.0)
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Assault/battery 142 (32.1)
d 90 (20.4)
Domestic violence-related assault
e 81 (18.3)
Other
Property 154 (16.1)
Sexual 147 (15.3)
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Incarcerated Suicide Decedents
n = 1,896
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Characteristic n (%)
Substance-related 224 (23.4)
Other 232 (24.2)
Upcoming release a
33 (1.7)
Source: NVDRS, 18 U.S. States, 2003–2014.
Note. Percentages may not add to 100% due to rounding. Offense types were not mutually exclusive, so percentages may add to over 100. NVDRS
= National Violent Death Reporting System.
a
Number of cases where this information was known.
b
Denominator for all “special housing” categories was all incarcerated suicide decedents.
c
Decedents were considered “recently incarcerated” if they were incarcerated for 6 months or less or the narrative stated that the decedent had
“recently” been incarcerated or detained.
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d
Cases were coded as having domestic violence–related crimes if the narrative identified the offense as a domestic violence or intimate partner
violence offense or if an offense involved current or former intimate partners.
e
Crimes in the “other” category included violation of a protective/restraining order, kidnapping, abduction, false imprisonment, child abuse and
neglect, other, unspecified personal crime.
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Table 3.
Characteristics of Asphyxia Deaths Among Incarcerated Suicide Decedents.
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Incarcerated Asphyxia Suicides
n = 1,745
Characteristic n (%)
Method of asphyxia
Hanging 1,701 (97.5)
Suffocation 21 (1.2)
Strangulation 21 (1.2)
Unspecified 2 (0.1)
Ligature mechanism a
1,218
Bedding 875 (71.8)
Clothing 132 (10.8)
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Clothing accessories 79 (6.5)
Towels/rags 40 (3.3)
Cords 50 (4.1)
Other 42 (3.4)
Anchoring point b
535
Bed 191 (35.7)
Bunk bed 157 (82.2)
Window 33 (6.2)
Ceiling 67 (12.5)
Door/cell bars 68 (12.7)
Air vent 76 (14.2)
Shower fixtures 33 (6.2)
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Plumbing 19 (3.6)
Stair railing 8 (1.5)
Other 40 (7.5)
Source: NVDRS, 18 U.S. States, 2003–2014.
Note. Percentages may not add to 100% due to rounding. NVDRS = National Violent Death Reporting System.
a
Number of asphyxia deaths with a specified ligature mechanism.
b
Number of hanging deaths with a specified ligature anchoring point.
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Table 4.
Time Incarcerated by Positive Toxicology Among Incarcerated Suicide Decedents Who Were Tested.
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Alcohol Marijuana Cocaine Opiates
Time Incarcerated n (%) n (%) n (%) n (%)
1 day or less
Available test result 133 81 112 110
Positive test result 46 (34.6) 19 (23.5) 13 (11.6) 8 (7.3)
2 to 7 days
Available test result 169 95 135 138
Positive test result 5 (3.0) 18 (19.0) 3 (2.2) 13 (9.4)
8 days to 1 month
Available test result 69 37 53 52
Positive test result 0 (0) 3 (8.1) 0 (0) 2 (3.9)
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31 days to 6 months
Available test result 61 47 58 58
Positive test result 1 (1.6) 0 (0) 0 (0) 2 (3.4)
a
Recently incarcerated (time unspecified)
Available test result 43 25 37 37
Positive test result 6 (14.0) 1 (4.0) 2 (5.4) 2 (5.4)
More than 6 months
Available test result 53 32 47 49
Positive test result 1 (1.9) 0 (0) 1 (2.1) 3 (6.1)
Unknown time incarcerated
Available test result 889 529 756 757
Positive test result 42 (4.7) 33 (6.2) 29 (3.8) 68 (9.0)
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Total
Available test result 1,417 846 1,198 1,201
Positive test result 101 (7.1) 74 (8.8) 48 (4.0) 98 (8.2)
Source: NVDRS, 18 U.S. States, 2003–2014.
Note. Percentages represent the proportion of decedents who tested positive for the substance of those who died within each incarceration period
and were tested for the substance. These substance classes represent a selection of the substance classes captured by NVDRS and were selected
because often they are used for recreational as opposed to medical purposes. NVDRS = National Violent Death Reporting System.
a
Incarceration periods described as “recent” in the narrative with no specific amount of time noted, or the decedent was incarcerated for 6 months
or less, but the specific amount of time was unknown.
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